MSK CT PROTOCOLS May 2010 Revision VCUHS Radiology MSK CT PROTOCOLS May 2010 Revision

MSK-01: MSK Chest Wall Protocols MSK-01 Basic Protocol 1st 2nd 3rd KVP/mAs (QRM)/Rotation time 120/350ma/1.0 sec   Collimation 64 x 1.2mm Slice Width 3.0 mm 1.2 mm Pitch 0.75 Kernel B30 B70 B30/B70 Increments 0.6 mm Image Order Cr - Cau FOV 180-200 mm Injection Rate Scan Delay Care Dose4D Yes PACS Notes: Soft tissue lesion: SAG, COR recons 3X3 send to PACS Bone lesion: Send both sets of Thin axials to PACS & Terra Sternum SC Joints Clavicle Axilla Ribs Chest Wall

MSK-01A: Sternum, SC Joints Indications: (-) trauma (+) mass, infection Use MSK-01 Basic protocol FOV Mark abnormality if present Sag/Cor reformats (angle coronals to sternum)

MSK-01A: Sternum, SC Joints Planes for Reformatted Images

Example Images: Sternum, SC Joints Sagittal Sternum Coronal Manubrium and SC joints Coronal Sternum

MSK-01B: Clavicle Indications: trauma Use MSK-01 Basic protocol FOV Cor, sag reformats

MSK-01C: Axilla, Ribs, Chest Wall (-,+) Indications: Trauma Mass, infection Use MSK-01 Basic protocol FOV (adjust as necessary) Mark abnormality Sag, Cor reformats Angled axial (along axis of ribs) may be useful for a specific rib abnormality

MSK-02: Shoulder/Arm (at side)* Shoulder/scapula Shoulder arthro Humerus Elbow* Forearm* Wrist/hand* MSK-02 Basic Protocol KVP/Effective mAs/Rotation time 120/300 ma 1.0 sec   Collimation 64 x 1.2mm Slice Width 3.0 mm 1.2 mm Pitch 0.75 Kernel B30 B70 B30/B70 Increments 0.6 mm Image Order Cr - Cau FOV 180-200 mm Injection Rate Scan Delay Care Dose4D Yes PACS Notes: Soft tissue lesion: SAG, COR recons 3X3 send to PACS Bone lesion: Send both sets of Thin axials to PACS & Terra *For elbow and distally, only perform with arm at side if patient unable to place arm over head for more ideal scanning.

MSK-02A: Shoulder/Scapula (-,+) Indications: (-) trauma (+) mass, infection Use MSK-02 Basic protocol FOV Mark abnormality Other arm above head Fracture / bone lesion: Paracoronal, parasagittal reformats (see examples) Soft Tissue lesion (mass, infection): perform straight coronals and sagittals Hardware: 140 kvp / 400 ma / 1.0 sec Collimation: 64 X 1.2 mm 3rd Recon: 1.2 mm X 0.6 mm

MSK-02A: Shoulder / Scapula Planes for (bone lesion) Reformatted Images Ideally, planes should be specified in 3 planes, although (A) is most important for scapula and shoulder joint. (B) and (C) are important for proximal humerus fractures

MSK-02B: Shoulder Arthrogram Shoulder Arthro Modified Protocol KVP/Effective mAs/Rotation time 120/300 ma 1.0 sec   Collimation 64 x 1.2mm Slice Width 3.0 mm 0.75 mm Pitch 0.75 Kernel B30 B70 B30/B70 Increments 0.5 mm Image Order Cr - Cau FOV 180-200 mm Injection Rate Scan Delay Care Dose4D Yes PACS Notes: Soft tissue lesion: SAG, COR recons 2X2 send to PACS Bone lesion: Send both sets of Thin axials to PACS & Terra Indications: post arthrogram FOV Use Use MSK-02 Basic protocol with changes in red at right Other arm above head Paracor/parasag reformats

MSK-02B: Shoulder Arthrogram Planes for Reformatted Images Ideally, parasagittal and paracoronal images should be prescribed in all 3 planes (axis of scapula and humerus)

Shoulder Arthrogram: Example Images

MSK-02C: Humerus (-,+) Indications: Use Basic MSK-02 protocol (-) trauma (+) mass, infection Use Basic MSK-02 protocol FOV (adjust as indicated) Mark abnormality Other arm above head Cor/sag reformats (angle to bone) Hardware: 140 kvp / 400 ma / 1.0 sec Collimation: 64 X 1.2 mm 3rd Recon: 1.2 mm X 0.6 mm

MSK-02C: Hummers (at Side) Planes for Reformatted Images For humerus, prescribe planes along long axis of humerus (A,B) and in plane of elbow joint (C) to give ideal coronal and sagittal view of humerus and upper arm

MSK-02D: Elbow (-,+) Indications: (-) trauma (+) mass, infection Use Basic MSK-02 protocol **Only perform with arm at side in patients unable to raise arm above head FOV (adjust FOV as necessary to cover abnormality) Other arm above head Sag/cor reformats (angle to long axis of humerus) For large Pt and/or arm across abdomen, may require max technique Hardware: 140 kvp / 400 ma / 1.0 sec Collimation: 64 X 1.2 mm 3rd Recon: 1.2 mm X 0.6 mm

MSK-02E: Forearm (-, +) Indications: Use Basic MSK-02 protocol (-) trauma (+) mass, infection Use Basic MSK-02 protocol **Only perform with arm at side in patients unable to raise arm above head FOV (adjust FOV as necessary to cover abnormality) Other arm above head Sag/cor reformats (angle to long axis of ulna) For large Pt and/or arm across abdomen, may require max technique Hardware: 140 kvp / 400 ma / 1.0 sec Collimation: 64 X 1.2 mm 3rd Recon: 1.2 mm X 0.6 mm

MSK-02F: Wrist/Hand (-,+) Indications: (-) trauma (+) mass, infection **Only perform with arm at side in patients unable to raise arm above head Adjust MSK02 protocol with changes as noted in red FOV (adjust FOV as necessary to cover abnormality) Other arm above head Sag/cor reformats For large Pt and/or arm across abdomen, may require max technique Hardware: 140 kvp / 400 ma / 1.0 sec Collimation: 64 X 1.2 mm 3rd Recon: 1.2 mm X 0.6 mm Wrist / Hand Modified Protocol VP/Effective mAs/Rotation time 120/300 ma 1.0 sec   Collimation 64 x 1.2mm Slice Width 2.0 mm 1.2 mm Pitch 0.75 Kernel B30 B70 B30/B70 Increments 0.6 mm Image Order Cr - Cau FOV 180-200 mm Injection Rate Scan Delay Care Dose4D Yes PACS Notes: Soft tissue lesion: SAG, COR recons 2x2 send to PACS Bone lesion: Send both sets of Thin axials to PACS & Terra

MSK-02G: Entire Arm (+) Indications: mass, infection Use Basic MSK02 protocol FOV (mark mass, adjust FOV as necessary to cover abnormality, elbow straight as possible) Other arm above head Slice thickness of 5mm x 5mm Sag/cor reformats (angle to long axis of humerus)

MSK-03: Arm (Over Head) Elbow Forearm Wrist Hand DRUJ study MSK-03 Basic Protocol 1st 2nd 3rd KVP/mAs(QRM) Rotation time 120/150ma/1.0 sec   Collimation 64 x 1.2 mm Slice Width 3.0 mm (Elb/FA) 2.0 mm (Wrist/Hand) 1.2 mm Pitch 0.75 Kernel B30 B70 B30B70 Increments 0.6 mm Image Order Cr - Cau FOV 120-180 mm as indicated Injection Rate Scan Delay Care Dose4D Yes PACS Notes: Sag, Cor 2x2 to PACS Send both sets of Thin axials to PACS & Terra Elbow Forearm Wrist Hand DRUJ study

MSK-03A: Elbow Indications: Use MSK-03 Basic Protocol (-) trauma (+) infection, mass Use MSK-03 Basic Protocol FOV (adjust FOV as necessary to cover abnormality, elbow straight as possible) Mark abnormality if present Sag/cor reformats (angle to long axis of humerus) This protocol may be use for isolated humerus abnormality Hardware: use 140 kV, 250 ma

MSK-03A: Elbow (Fx) Planes for Reformatted Images Planes must be prescribed carefully and in 3 planes in order to achieve true axial (A), coronal (B), and sagittal (C) images.

MSK-03A: Example Images

MSK-03B: Forearm (-,+) Indications: Use MSK-03 Basic Protocol (-) trauma (+) mass, infection Use MSK-03 Basic Protocol FOV (adjust FOV as necessary to cover abnormality) Mark abnormality, elbow straight as possible Sag/cor reformats (angle to long axis of ulna) Hardware: use 140 kV, 250 ma

MSK-03C: Wrist/Hand (-,+) High Res Hand / Wrist Modified Protocol Indications: (-) trauma (+) mass, infection Use MSK-03 Basic Protocol For High Res study, see modifications at right (must be isocenter) FOV (adjust FOV as necessary to cover abnormality, wrist and fingers straight as possible) Sag/cor reformats (angle to long axis of radius) Hardware: use 140 kV, 250 ma VP/Effective mAs/Rotation time 120/150 ma 1.0 sec   Collimation 12 x 0.6 mm Slice Width 2.0 mm 0.75 mm Pitch 0.75 Kernel B30 U70 B30/U70 Increments 0.5 mm Image Order Cr - Cau FOV 120-150 mm Or as indicated Injection Rate Scan Delay Care Dose4D Yes PACS Notes: Soft tissue lesion: SAG, COR recons 2x2 send to PACS Bone lesion: Send both sets of Thin axials to PACS & Terra

MSK-03C: Hand / Wrist Planes for Reformatted Images

MSK-03A: Wrist- DRUJ Study Indications: Distal Radio-ular joint (DRUJ) abnormality Use MSK-03 Basic Protocol (high res may be necessary for one of the three scans) FOV Scan BOTH wrists separately in the arm overhead position Scan in 3 positions: Neutral Full pronation Full supination Be sure to label R/L and which position for each series Use High-Res technique with Sag/Cor recons for neutral position only

MSK-04 Basic Bony Pelvis Protocol MSK-04: Pelvis/Hips Pelvis (bone) Hips (bilateral) Hip (unilateral) Acetabular dysplasia study MSK-04 Basic Bony Pelvis Protocol KVP/Effective mAs/Rotation time 120/300 ma 1.0 sec   Collimation 64 x 1.2mm Slice Width 3.0 mm 1.2 mm Pitch 0.75 Kernel B30 B60 B30/B60 Increments 0.6 mm Image Order Cr - Cau FOV 380 mm Injection Rate Scan Delay Care Dose4D Yes PACS Notes: Soft tissue lesion: SAG, COR recons 3X3 send to PACS Bone lesion: Send both sets of Thin axials to PACS & Terra

MSK-04A: Pelvis (bone) (-,+) Indications: (-) trauma (+) mass, infection Use MSK-04 Basic Protocol FOV (legs straight as possible) Sag/cor reformats Hardware: use 140 kV, 400 ma

MSK-04B: Hips (-) Indications: trauma Use MSK-04 Basic Protocol FOV (legs straight as possible) Use MSK-04 Basic Protocol Sag/cor reformats Hardware: use 140 kV, 400 ma

MSK-04C: Acetabular Dysplasia Study (-) Indications: suspected acetabular dysplasia Use MSK-04 Basic Protocol FOV (legs straight and symmetric as possible, toes straight up and together) Sag/Cor and 3-D reformats

MSK-04D: Hip (unilateral) Indications: post arthrogram Bony tumor FOV (legs straight as possible) Sag/cor reformats Use MSK-04 Basic Protocol

MSK-04D: Hip Planes for Reformatted Images C B Prescribe in sagittal (B) and coronal (C) planes off the axial (A). Additional angling in the long axis of the femur (off the sagittal) yields nice images of femur (C)

MSK-05 Basic Lower Ext Protocol MSK-05: Lower Extremity MSK-05 Basic Lower Ext Protocol KVP/Effective mAs/Rotation time 120/250 ma 1.0 sec   Collimation 64 x 1.2mm Slice Width 3.0 mm 1.2 mm Pitch 0.75 Kernel B30 B70 B30/B70 Increments 0.6 mm Image Order Cr - Cau FOV 300 mm Or as indicated Injection Rate Scan Delay Care Dose4D Yes PACS Notes: Soft tissue lesion: SAG, COR recons 3X3 send to PACS Bone lesion: Send both sets of Thin axials to PACS & Terra Femurs (unilateral, bilateral) Knee Tib/fib (unilateral, bilateral) Ankle/Hindfoot/Calcaneus Foot Entire leg Miscellaneous “Version” study Patellar tracking study

MSK-05A: Femurs (bilateral) Indications: mass, infection Use MSK-05 Basic Protocol FOV (legs straight as possible) Sag/cor reformats Hardware: use 140 kV, 400 ma

MSK-05B: Femur (unilateral) (+,-) Indications: (-) trauma (+) mass, infection Use MSK-05 Basic Protocol FOV (legs straight as possible) Sag/cor reformats, angle along long axis of femur Hardware: use 140 kV, 350 ma

MSK-05C: Entire Leg (unilateral) (+) Entire Leg Modified Protocol Indications: Mass, infection Use modified protocol at right FOV (legs straight as possible) Sag/cor reformats (angle along long axis of femur Hardware: use 140 kV, 300 ma KVP/Effective mAs/Rotation time 120/250 ma 1.0 sec   Collimation 64 x 1.2mm Slice Width 5.0 mm 2.0 mm Pitch 0.75 Kernel B30 B70 B30/B70 Increments 1.0 mm Image Order Cr - Cau FOV 300 mm Or as indicated Injection Rate Scan Delay Care Dose4D Yes PACS Notes: Soft tissue lesion: SAG, COR recons 5x5 send to PACS Bone lesion: Send both sets of Thin axials to PACS & Terra

MSK-05D: Knee (unilateral) Indications: trauma (-) mass, infection (+) Use MSK-05 Basic Protocol FOV (knee straight as possible) Mark mass if present Sag/Cor reformats (angle to posterior femoral condyles if possible) Hardware: use 140 kV, 300 ma

MSK-05D: Knee: Planes for Reformatted Images C B Prescribe in sagittal (B) and coronal (C) planes off the axial (A). Use posterior femoral condyles to prescribe coronal and sagittal reformats (A, thick red line)

MSK-05E: Tib/Fib (unilateral) (-,+) Indications: (-) trauma (+) mass, infection Use MSK-05 Basic Protocol FOV (knee straight as possible) Mark abnormality if present Sag/Cor reformats (angle to long axis of tibia) Hardware: use 140 kV, 300 ma

MSK-05E: Tib/Fib Planes for Reformatted Images C Prescribe in sagittal (B) and coronal (C) planes off the axial (A). Use posterior femoral condyles or midline of proximal tibia (A, thick red line) to prescribe coronal and sagittal reformats

MSK-05F: Ankle/Hindfoot Indications: (-) trauma (+) mass, infection Use modified MSK-05 Basic Protocol on right FOV (foot at 90 degrees if possible) Sag/Cor reformats (angle to approx axis of foot) Hardware: use 140 kV, 300 ma Ankle/Hindfoot Modified Protocol KVP/Effective mAs/Rotation time 120/200 ma 1.0 sec   Collimation 64 x 0.6mm Slice Width 2.0 mm 0.75 mm Pitch 0.75 Kernel B30 B70 B30/B70 Increments 0.5 mm Image Order Cr - Cau FOV 150 mm Or as indicated Injection Rate Scan Delay Care Dose4D Yes PACS Notes: Soft tissue lesion: SAG, COR recons 2x2 send to PACS Bone lesion: Send both sets of Thin axials to PACS & Terra

MSK-05F: Ankle/Hindfoot/Calcaneus Planes for Reformatted Images B C Prescribe in sagittal (B) and coronal (C) planes off the axial (A). Use approximate long axis of calcaneus (A, thick red line) to prescribe coronal and sagittal reformats

MSK-05G: Foot (-,+) Indications: (-) trauma (+) mass, infection Use Modified MSK-05 Protocol (same as Ankle/Hindfoot FOV (foot at 90 degrees if possible) Sag/Cor reformats (angle to long and short axes of metatarsals – see red lines at left) Hardware: use 140 kV, 300 ma

MSK-05G: Foot Planes for Reformatted Images C B A Prescribe in sagittal (B) and coronal (C) planes off the short axis plane (A). For midfoot, use axis of 2nd-5th MT’s (A, thick red line) to prescribe coronal and sagittal reformats. Depending upon positioning of patient in scanner, short axis plane (A) may need to be derived from original images as well.

MSK-05H: Patellar Tracking Study Modified MSK-05: Patellar Tracking Protocol Indications: Patellar tracking abnormalities FOV (legs symmetric as possible) Scan in four positions: 0, 15, 30, 45 degrees of flexion Use Modified MSK-05 Basic Protocol (Rt) Archive thin sections from 1st position only KVP/Effective mAs/Rotation time 120/150 ma 1.0 sec   Collimation 64 x 1.2mm Slice Width 3.0 mm 1.2 mm* Pitch 0.75 Kernel B30 B70 B30/B70 Increments 0.6 mm Image Order Cr - Cau FOV Both Knees Injection Rate Scan Delay Care Dose4D Yes PACS Notes: *Soft tissue lesion: SAG, COR recons 3X3 send to PACS *Bone lesion: *Send both sets of Thin axials to PACS & Terra *Send thin images and recons for 1st (extended) position

MSK-05I: Femoral Anteversion Study Indications: lower extremity alignment abnormalities Use Modified MSK-05 Basic Protocol (Rt) Keep FOV the same for all 3 scans Legs straight as possible Must not move between scans AP scout from top of femur to ankle joint (need to be able to measure limb lengths) Axials only Modified MSK-05: Anteversion Study KVP/Effective mAs/Rotation time 120/200 ma 1.0 sec   Collimation 64 x 1.2mm Slice Width 3.0 mm 1.2 mm* Pitch 0.75 Kernel B30 B70 B30/B70 Increments 0.6 mm Image Order Cr - Cau FOV Both legs Injection Rate Scan Delay Care Dose4D Yes PACS Notes: Send axials To PACS

MSK-06. Ortho Spine C-spine (-,+) T-spine (-,+) L-spine (-,+) Post-Discogram (C, T, or L)